Initial Comments:
Based on the findings of an unannounced, onsite state licensure complaint investigation survey conducted on March 14, 2024, with the off-site portion of the survey being completed on March 15, 19 and 20, 2024, Platinum Private Duty was found not to be in compliance with the following requirement of Title 28 Pa Code, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
51.3 (g)(1-14) LICENSURE
NOTIFICATION
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51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
Observations:
Based on review of agency policies/procedures, documentation, consumer (agency) files and the Pennsylvania (PA) Department of Health (DOH) Event Reporting System (ERS) website, and based on interview with the Director of Operations (DOO-Employee #4) and the Administrator (Employee #6), the agency failed to submit a report of one (1) of three (3) consumer related incidents/allegations to the PA DOH ERS website which were reported to the agency since June 2023. (Consumer #1)
Findings included:
On March 20, 2024 at approximately 1:42 PM, review of the agency policy titled "Event Reporting Policy" revealed the following: It is the policy of Platinum Private Duty to report significant incidents regarding direct care workers and consumers to the PA (Pennsylvania) Department of Health...
On March 20, 2024 at approximately 3:12 PM, review of the employee handbook revealed the following:
"Suspected Abuse/Neglect Policy"...
Platinum Private Duty will report all types of suspected abuse and neglect or other victimization...
Consumer #1: On March 15, 2024 at approximately 12:57 PM, March 19, 2024 at approximately 1:30 PM and March 20, 2024 at approximately 11:18 AM, review of the consumer file revealed home care services were provided between 01/17/2024 and 03/08/2024.
Review of email attachment documentation dated 03/15/2024 revealed the consumer left a voicemail on 02/28/2024 in which the consumer reported that the consumer was experiencing issues. The Relief Intake Manager (Employee #5) documented that Employee #5 had instructed the consumer contact the agency to discuss the concerns and also to contact the local police department if the consumer's concerns required attention.
Review of email documentation dated 03/20/2024 revealed the Employee #5 reported the consumer was instructed to contact the police because the consumer reported that items had been stolen.
On March 20, 2024 at approximately 11:08 AM, review of the PA DOH ERS website revealed reportable incidents included "Misappropriation of Patient/Resident Property". There was no documentation on the PA DOH ERS website which provided evidence that the agency had submitted a report to the PA DOH ERS website under the aforementioned category for the above referenced incident/allegation reported by Consumer #1.
During telephone interview conducted on March 20, 2024 at approximately 3:30 PM, the DOO and the Administrator confirmed the agency failed to submit a report to the PA DOH ERS website for the above referenced incident/allegation reported by Consumer #1.
Plan of Correction:Platinum Private Duty will adhere to PA Code 51.3, as well as internal policies related to event reporting. We will ensure that any and all complaints, no matter their form (verbal, written, voice message, email, or text message), are promptly filed upon receipt. Within 24 hours of the incident, a report will be submitted through the Department of Health event reporting site. Following this, we will conduct an internal investigation to assess the validity of the accusation. Once contact is established with the accusing party, Platinum Private Duty will update the initial report to include any additional findings. The Director of Operations will receive all complaints, and incidents and they will be reported accordingly to the Department of Health Incident reporting site.There will be a weekly check list developed for any reportable incidents to ensure that no incidents are overlooked and are reported in a timely manner, this list will be monitored by the Director of Operations.
Initial Comments:
Based on the findings of an unannounced, onsite state licensure complaint investigation survey conducted on March 14, 2024, with the off-site portion of the survey being completed on March 15, 19 and 20, 2024, Platinum Private Duty was found not to be in compliance with the following requirements of Title 28 Health and Safety Part IV, Health Facilities, Subpart H. Chapter 611 Home Care Agencies and Home Care Registries.
Plan of Correction:
611.52(a) LICENSURE
Criminal Background Checks
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The home care agency or home care registry shall require each applicant for employment or referral as a direct care worker to submit a criminal history report obtained at the time of application or within 1 year immediately preceding the date of application.
Observations:
Based on review of agency policies and procedures, documentation, personnel and agency (consumer) files, and based on interview with the Director of Operations (DOO-Employee #4) and the Administrator (Employee #6), the agency failed to ensure a Pennsylvania State Police (PSP) "Response for Criminal Record" (PSP Criminal Background Check) had been requested prior to the assignment of three (3) of three (3) direct care workers (DCW) to provide home care services. (Employees #1, #2 and #3)
Findings include:
On March 20, 2024 at approximately 1:41 PM, review of the agency policy titled "Selection & Hiring Policy" revealed the following under "Criminal Background Checks":
It is our policy to conduct a criminal background check on all direct care workers...
On March 20, 2024 between the approximate times of 9:02 AM and 10:13 AM, review of personnel file documentation revealed the following:
Employee #1: The first date the DCW was assigned to provide home care services was 02/08/2024.
Employee #2: The first date the DCW was assigned to provide home care services was 01/25/2024.
Employee #3: The first date the DCW was assigned to provide home care services was 11/09/2023.
Review of criminal history report documentation revealed the PSP "Response for Criminal Record" reports for the above identified DCW's were requested on 03/18/2024 which was after the DCW's were assigned to provide home care services.
Consumer #1: On March 15, 2024 at approximately 12:57 PM, March 19, 2024 at approximately 1:30 PM and March 20, 2024 at approximately 11:18 AM, review of the agency file revealed home care services were provided by Employee #1 in February 2024, by Employee #2 in January 2024 and Employee #3 in March 2024.
During telephone interview conducted on March 20, 2024 at approximately 3:30 PM, the DOO and the Administrator confirmed a PSP "Response for Criminal Record" had not been requested prior to the assignment of the above referenced DCW's to provide home care services.
Plan of Correction:Platinum Private Duty will adhere to article 611.52(a) regarding Criminal Background Checks. We will conduct thorough background checks for all prospective employees, at the time of offering and acceptance of a position within the agency all background checks will be completed, including a PA Criminal Background check.
All background checks will be carried out exclusively by the Director of Operations and will be completed before any employee begins providing services. A designated location will be allocated for all new hire files, and the file audit checklist will be utilized to verify the receipt of all background checks before the file is placed in the permanent employee cabinet. If an employee's file remains in the holding area then that employee will function under the 30 provisional hire policy and will be monitored until their background checks have been returned and are deemed acceptable. This process will be completed by the Scheduling Coordinator and overseen by the Director of Operations.
611.57(a) LICENSURE
Consumer Rights
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(a) The consumer of home care services provided by a home care agency or through a home care registry shall have the following rights: (1) To be involved in the service planning process and to receive services with reasonable accommodation of individual needs and preferences, except where the health and safety of the direct care worker is at risk. (2) To receive at least 10 calendar days advance written notice of the intent of the home care agency or home care registry to terminate services. Less than 10 days advance written notice may be provided in the event the consumer has failed to pay for services, despite notice, and the consumer is more than 14 days in arrears, or if the health and welfare of the direct care worker is at risk.
Observations:
Based on review of agency policies/procedures, documentation and agency (consumer) files, and based on interview with the Director of Operations (DOO-Employee #4) and the Administrator (Employee #6), the agency failed to ensure three (3) of three (3) consumers participated in planning for changes to the care plan. (Consumers #1, #2 and #3)
Findings include:
On March 20, 2024 at approximately 9:24 AM, review of the "Client Handbook" revealed the following:
"Bill of Rights": Decision Making...Patients have the right...To be advised of any change in the plan of care before the change is made. To participate in the planning of care and in planning changes in the care...
"Consumer Bill of Rights & Responsibilities"...2. The right to be involved in the service planning process...4. The right to know of changes in our services/care before those changes occur...
On March 20, 2024 at approximately 1:42 PM, review of the agency policy titled "Working With Consumers Policy" revealed the following: All tasks should be entered...
Consumer #1: On March 15, 2024 at approximately 12:57 PM, March 19, 2024 at approximately 1:30 PM and March 20, 2024 at approximately 11:18 AM, review of the consumer file revealed home care services were to be provided ten (10) hours per day for seven (7) days per week as documented on the intake form dated 01/17/2024 and that home care services are to include, but were not limited to, the following service: Bathing, meal preparation and medication reminders.
Review of direct care worker (DCW) task and timesheet documentation revealed the following:
There was no record home care services were provided on 02/01/2024.
Less than 10 hours of services were provided on 02/06, 02/07, 02/09, 02/12, 02/13, 02/16, 02/19, 02/21, 02/22, 02/26, 02/27 and 03/04/2024.
The following tasks were documented as being incomplete or "none":
Bathing: 01/18, 01/19, 01/26, 02/06, 02/12, 02/15, 02/19, 02/22, 02/23 and 03/04/2024.
Meal Preparation: 01/26, 02/23 and 02/26/2024; and
Medication Reminders: 01/26 and 02/19/2024.
There was no documentation in the agency file which provided evidence the consumer was notified of the care plan changes related to the days/hours services would be provided and there was no documentation which provided evidence the consumer had refused bathing, meal preparation and medication reminders on the above referenced dates.
Consumer #2 (Discharge): On March 15, 2024 at approximately 1:04 PM, March 19, 2024 at approximately 3:24 PM and March 20, 2024 at approximately 8:49 AM, review of the consumer file revealed home care services were to be provided four (4) hours per day for six (6) days per week as documented on the intake form dated 02/05/2024.
Review of DCW task and timesheet documentation revealed the following:
Less than four (4) hours of services were provided for ten (10) of ten (10) DCW shifts completed between 02/14 and 03/07/2024.
There was no documentation in the agency file which provided evidence the consumer was notified of the care plan changes related to the hours services would be provided.
During interview conducted on March 20, 2024 at approximately 3:25 PM, the DOO reported the DCW was routinely dismissed prior to the end of the scheduled hours but confirmed there was no documentation in the agency file which provided evidence the consumer had dismissed the DCW prior to the end of the shifts.
Consumer #3: On March 15, 2024 at approximately 1:10 PM, March 19, 2024 at approximately 3:37 PM and March 20, 2024 at approximately 8:57 AM, review of the consumer file revealed home care services were to include, but were not limited to, the following as documented on the intake form dated 01/15/2024: Bathing and all activities of daily living (ADL's).
Review of DCW task and timesheet documentation revealed the following:
DCW tasks are to include, but are not limited to, bathing, meal preparation (prepare dinner) and medication reminders.
The following tasks were documented as being incomplete or "none":
Bathing and medication reminders on 01/20, 01/22, 01/29, 02/26 and 03/12/2024 and meal preparation on 01/24 and 03/07/2024.
There was no documentation in the agency file which provided evidence the consumer had refused bathing, meal preparation nor medication reminders on the above referenced dates.
During interview conducted on March 20, 2024 at approximately 3:25 PM, the DOO reported software accessibility issues may have resulted in the DCW tasks being documented as "none" and that the consumer's family would take the consumer out to dinner; therefore, meal preparation was not necessary. The DOO confirmed there was no documentation in the agency file which provided evidence the consumer had refused bathing, meal preparation and medication reminders on the above referenced dates.
During telephone interview conducted on March 20, 2024 at approximately 3:25 PM, the DOO and the Administrator confirmed that the agency file failed to include documentation which provided evidence the above identified consumers were made aware of the care plan changes related to the days/hours services would be provided and that there no was documentation which provided evidence the consumers had refused the above referenced home care services on the aforementioned dates.
Plan of Correction:1.Platinum Private will adhere to article 611.57(a) on Consumer Rights: We will follow the details outlined in the consumer's care plan and the authorized hours of service. Should a consumer request a change in their care plan or authorized schedule, documentation will be added to the consumer's file. Additionally, the Service Coordinator will be promptly notified of any requested changes. If a client requests flexibility in their authorized hours, it will be clearly documented on their care plan that hours may vary based on the consumer's request to adjust time and days of services. Any adjustments to the hours or days of services will be documented, and the Service Coordinator will be informed accordingly.
2.If a consumer refuses any modalities listed on their care plan, the reason for refusal will be documented in the task section of Clear Care and become a part of the consumer's record. Should refusals become excessive, the Service Coordinator will be notified so the/she can attempt to resolve the issue, or make adjustments to the original care plan.
3.The task section of Clear Care (Care Specialists documentation area) will undergo monitoring throughout the work day by the Scheduling Coordinator an additional check will be done at the completion of every business day and again at the beginning of the next business day to ensure accuracy and completion.
4.Care staff will receive re-education on how to properly document when a consumer veers from the original care plan. "N/A" will not be an acceptable response to a consumer refusing a modality; instead, a written response depicting the reason for refusal must be provided.
The Scheduling Coordinator will have the daily responsibility of monitoring all consumer task entries,and documentation input for all missed visits, as well as reasons for refusal of any modalities outlined in the consumer's care plan. The Director of Operations will oversee this process to ensure compliance.
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